{"id":37052,"date":"2026-06-16T21:26:13","date_gmt":"2026-06-16T15:56:13","guid":{"rendered":"https:\/\/atsixty.com\/?p=37052"},"modified":"2026-06-16T21:26:14","modified_gmt":"2026-06-16T15:56:14","slug":"upper-gi-surgeryoesophagus-stomach-duodenum","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/uncategorized\/upper-gi-surgeryoesophagus-stomach-duodenum\/","title":{"rendered":"Upper GI SurgeryOesophagus, Stomach &amp; Duodenum"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Upper GI Surgery<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n#surg01 *,#surg01 *::before,#surg01 *::after{box-sizing:border-box;margin:0;padding:0}\n#surg01{\n  --surg:#2C5F8A;\n  --surg-light:#3A78A8;\n  --surg-pale:#EBF2F8;\n  --surg-dark:#1E4464;\n  --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n  --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n  --ink:#1A2A38;--ink-mid:#3A5A6A;--ink-soft:#7A98AD;\n  --line:#D6E5EE;--cream:#F4F8FB;--warm:#FAFCFE;\n  font-family:'Source Serif 4',Georgia,serif;\n  font-size:16px;color:var(--ink);background:var(--cream);\n  line-height:1.7;padding:0 0 64px;\n}\n#surg01 .mr-header{background:var(--surg);color:#EEF5FA;padding:34px 24px 28px;text-align:center}\n#surg01 .mr-eyebrow{font-size:0.68rem;letter-spacing:0.18em;text-transform:uppercase;font-weight:600;opacity:0.65;margin-bottom:10px}\n#surg01 .mr-title{font-family:'Playfair Display',serif;font-size:1.75rem;font-weight:700;line-height:1.2;margin-bottom:4px}\n#surg01 .mr-title em{font-style:italic;font-weight:400;opacity:0.88}\n#surg01 .mr-subtitle{font-size:0.82rem;opacity:0.7;margin-top:8px;font-style:italic}\n#surg01 .mr-chips{display:flex;justify-content:center;gap:10px;margin-top:18px;flex-wrap:wrap}\n#surg01 .mr-chip{background:rgba(255,255,255,0.13);border:1px solid rgba(255,255,255,0.22);border-radius:20px;padding:4px 13px;font-size:0.73rem}\n#surg01 .mr-sentinel{height:1px}\n#surg01 .mr-progress{position:fixed;top:0;left:0;right:0;z-index:9999;background:var(--warm);border-bottom:1px solid var(--line);box-shadow:0 2px 12px rgba(26,42,56,0.08);padding:9px 16px;display:none}\n#surg01 .mr-progress.visible{display:block}\n#surg01 .mr-prog-inner{max-width:720px;margin:0 auto;display:flex;align-items:center;justify-content:center}\n#surg01 .mr-pips{display:flex;align-items:center;justify-content:center}\n#surg01 .mr-pip-wrap{display:flex;align-items:center}\n#surg01 .mr-pip-line{width:28px;height:2px;background:var(--line);transition:background 0.35s}\n#surg01 .mr-pip-line.done{background:var(--surg)}\n#surg01 .mr-pip{width:28px;height:28px;border-radius:50%;border:2px solid var(--line);background:var(--warm);display:flex;align-items:center;justify-content:center;font-size:0.63rem;font-weight:700;color:var(--ink-soft);transition:all 0.3s;flex-shrink:0}\n#surg01 .mr-pip.correct{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#surg01 .mr-pip.wrong{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#surg01 .mr-body{max-width:720px;margin:0 auto;padding:0 16px}\n#surg01 .mr-case{background:var(--warm);border:1px solid var(--line);border-left:4px solid var(--surg);border-radius:10px;margin:28px 0;overflow:hidden;box-shadow:0 1px 6px rgba(26,42,56,0.05)}\n#surg01 .mr-case-top{padding:16px 20px 14px;display:flex;gap:14px;align-items:flex-start}\n#surg01 .mr-num{font-family:'Playfair Display',serif;font-size:2.2rem;font-weight:700;color:var(--surg);opacity:0.16;line-height:1;margin-top:-2px;flex-shrink:0}\n#surg01 .mr-meta{flex:1}\n#surg01 .mr-tag{font-size:0.61rem;font-weight:700;letter-spacing:0.14em;text-transform:uppercase;color:var(--surg);opacity:0.75;margin-bottom:5px}\n#surg01 .mr-stem{font-size:0.94rem;color:var(--ink);line-height:1.72}\n#surg01 .mr-stem strong{font-weight:600}\n#surg01 .mr-stem em{font-style:italic}\n#surg01 .mr-rule{height:1px;background:var(--line);margin:0 20px}\n#surg01 .mr-opts{padding:12px 20px 16px;display:flex;flex-direction:column;gap:8px}\n#surg01 .mr-opt{display:flex;align-items:flex-start;gap:11px;padding:10px 14px;border:1.5px solid var(--line);border-radius:8px;cursor:pointer;background:var(--warm);transition:border-color 0.15s,background 0.15s;-webkit-tap-highlight-color:transparent}\n#surg01 .mr-opt:hover{border-color:var(--surg);background:var(--surg-pale)}\n#surg01 .mr-opt.locked{cursor:default}\n#surg01 .mr-opt.locked:hover{border-color:var(--line);background:var(--warm)}\n#surg01 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.mr-opt-text{font-size:0.9rem;color:var(--ink-mid);line-height:1.58}\n#surg01 .mr-opt.correct .mr-opt-text{color:var(--correct);font-weight:600}\n#surg01 .mr-opt.wrong .mr-opt-text{color:var(--wrong)}\n#surg01 .mr-exp{display:none;border-top:1px solid #b8d4e4;background:linear-gradient(180deg,#e4f0f7 0%,#f0f7fb 100%);padding:13px 20px 15px}\n#surg01 .mr-exp-lbl{font-size:0.61rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:#1a5070;margin-bottom:6px}\n#surg01 .mr-exp-text{font-size:0.86rem;color:#12324A;line-height:1.68}\n#surg01 .mr-exp-text strong{font-weight:600}\n#surg01 .mr-exp-text em{font-style:italic}\n#surg01 .mr-img-wrap{margin-top:14px;background:var(--warm);border:1px solid var(--line);border-radius:8px;padding:14px;text-align:center}\n#surg01 .mr-img-wrap figcaption{font-size:0.73rem;color:var(--ink-soft);font-style:italic;margin-top:8px;line-height:1.4}\n#surg01 .mr-submit-wrap{text-align:center;padding:28px 16px 8px}\n#surg01 .mr-btn{background:var(--surg);color:#EEF5FA;border:none;border-radius:8px;padding:13px 44px;font-family:'Playfair Display',serif;font-size:1rem;font-weight:700;cursor:pointer;box-shadow:0 2px 8px rgba(44,95,138,0.28)}\n#surg01 .mr-btn:hover{background:var(--surg-dark)}\n#surg01 .mr-score{display:none;background:var(--warm);border:1px solid var(--line);border-top:4px solid var(--surg);border-radius:10px;margin:24px 0 0;box-shadow:0 2px 12px rgba(26,42,56,0.08);overflow:hidden}\n#surg01 .mr-score-in{padding:28px 24px;text-align:center}\n#surg01 .mr-score-ey{font-size:0.66rem;letter-spacing:0.14em;text-transform:uppercase;color:var(--ink-soft);margin-bottom:12px;font-weight:600}\n#surg01 .mr-ring{width:98px;height:98px;border-radius:50%;background:conic-gradient(var(--surg) 0%,var(--line) 0%);display:flex;align-items:center;justify-content:center;margin:0 auto 16px;position:relative}\n#surg01 .mr-ring::before{content:'';position:absolute;width:76px;height:76px;border-radius:50%;background:var(--warm)}\n#surg01 .mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#surg01 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--surg)}\n#surg01 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#surg01 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#surg01 .mr-score-net{font-size:0.9rem;color:var(--surg);font-weight:600;margin-bottom:4px}\n#surg01 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#surg01 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#surg01 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#surg01 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#surg01 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#surg01 .mr-band-s{background:var(--surg-pale);color:var(--surg)}\n#surg01 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--surg);color:var(--surg);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#surg01 .mr-retry:hover{background:var(--surg);color:#EEF5FA}\n@media(max-width:480px){#surg01 .mr-title{font-size:1.4rem}#surg01 .mr-num{font-size:1.7rem}#surg01 .mr-stem{font-size:0.9rem}#surg01 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- SVG Q1: Achalasia \u2014 barium swallow bird-beak + LES pathophysiology -->\n<div id=\"surg01-img1\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 200\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"200\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Achalasia \u2014 Pathophysiology &amp; Manometric Pattern<\/text>\n      <!-- Oesophagus column -->\n      <rect x=\"10\" y=\"24\" width=\"130\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"75\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Feature<\/text>\n      <rect x=\"145\" y=\"24\" width=\"200\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"245\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Normal<\/text>\n      <rect x=\"350\" y=\"24\" width=\"200\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"450\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Achalasia<\/text>\n      <!-- Row 1 -->\n      <rect x=\"10\" y=\"48\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"66\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">LES tone<\/text>\n      <rect x=\"145\" y=\"48\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"245\" y=\"66\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Normal (15\u201335 mmHg); relaxes with swallow<\/text>\n      <rect x=\"350\" y=\"48\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"450\" y=\"59\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Elevated (&gt;45 mmHg);<\/text>\n      <text x=\"450\" y=\"70\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">fails to relax<\/text>\n      <!-- Row 2 -->\n      <rect x=\"10\" y=\"78\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"96\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Oesophageal body<\/text>\n      <rect x=\"145\" y=\"78\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"245\" y=\"96\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Progressive peristaltic contractions<\/text>\n      <rect x=\"350\" y=\"78\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"450\" y=\"89\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Aperistalsis<\/text>\n      <text x=\"450\" y=\"100\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">(simultaneous contractions)<\/text>\n      <!-- Row 3 -->\n      <rect x=\"10\" y=\"108\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"126\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Cells lost<\/text>\n      <rect x=\"145\" y=\"108\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"245\" y=\"126\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Myenteric plexus intact<\/text>\n      <rect x=\"350\" y=\"108\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"450\" y=\"119\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Auerbach's (myenteric) plexus<\/text>\n      <text x=\"450\" y=\"130\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">NO inhibitory neurons (NO \/ VIP)<\/text>\n      <!-- Row 4 \u2014 Barium finding -->\n      <rect x=\"10\" y=\"138\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"156\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Barium swallow<\/text>\n      <rect x=\"145\" y=\"138\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"245\" y=\"156\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Smooth tapering at GEJ<\/text>\n      <rect x=\"350\" y=\"138\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"450\" y=\"149\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">\"Bird-beak\" \/ \"Rat-tail\"<\/text>\n      <text x=\"450\" y=\"160\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Dilated body + narrow GEJ<\/text>\n      <!-- Treatment row -->\n      <rect x=\"10\" y=\"168\" width=\"540\" height=\"26\" rx=\"3\" fill=\"#2C5F8A\" opacity=\"0.12\"\/>\n      <text x=\"280\" y=\"179\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Treatment ladder: <\/text>\n      <text x=\"280\" y=\"190\" text-anchor=\"middle\" fill=\"#2C5F8A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Pneumatic dilation (1st line non-surgical) \u2192 Heller's cardiomyotomy + partial fundoplication (surgical gold standard) \u2192 POEM<\/text>\n    <\/svg>\n    <figcaption>\n      Achalasia: loss of inhibitory (NO\/VIP-secreting) neurons in Auerbach's plexus \u2192 unopposed LES tone + aperistalsis. Gold-standard diagnosis is <strong>high-resolution manometry<\/strong>. Barium swallow shows the classic bird-beak; endoscopy is mandatory to exclude pseudoachalasia (carcinoma of GEJ mimicking achalasia \u2014 always suspect if age &gt;60, rapid weight loss, or short history).\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q3: Modified Johnson's Classification of Peptic Ulcers -->\n<div id=\"surg01-img3\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 215\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"215\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Modified Johnson's Classification \u2014 Gastric Ulcer<\/text>\n      <!-- Header -->\n      <rect x=\"10\" y=\"24\" width=\"60\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"74\" y=\"24\" width=\"180\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"258\" y=\"24\" width=\"130\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"392\" y=\"24\" width=\"158\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"40\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Type<\/text>\n      <text x=\"164\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Site<\/text>\n      <text x=\"323\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Acid<\/text>\n      <text x=\"471\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Key note<\/text>\n      <!-- Type I -->\n      <rect x=\"10\" y=\"48\" width=\"60\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"40\" y=\"66\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"9\" font-family=\"Georgia,serif\" font-weight=\"bold\">I<\/text>\n      <rect x=\"74\" y=\"48\" width=\"180\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"164\" y=\"60\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Lesser curvature, incisura<\/text>\n      <text x=\"164\" y=\"71\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">angularis (MC type, ~60%)<\/text>\n      <rect x=\"258\" y=\"48\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"323\" y=\"66\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Normal or low<\/text>\n      <rect x=\"392\" y=\"48\" width=\"158\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"471\" y=\"60\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">H. pylori most common;<\/text>\n      <text x=\"471\" y=\"71\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Lowest malignancy risk<\/text>\n      <!-- Type II -->\n      <rect x=\"10\" y=\"78\" width=\"60\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"40\" y=\"96\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"9\" font-family=\"Georgia,serif\" font-weight=\"bold\">II<\/text>\n      <rect x=\"74\" y=\"78\" width=\"180\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"164\" y=\"90\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Body + concurrent<\/text>\n      <text x=\"164\" y=\"101\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">duodenal ulcer<\/text>\n      <rect x=\"258\" y=\"78\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"323\" y=\"96\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">High<\/text>\n      <rect x=\"392\" y=\"78\" width=\"158\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"471\" y=\"90\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Treat as duodenal ulcer<\/text>\n      <text x=\"471\" y=\"101\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">(acid-driven)<\/text>\n      <!-- Type III -->\n      <rect x=\"10\" y=\"108\" width=\"60\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"40\" y=\"126\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"9\" font-family=\"Georgia,serif\" font-weight=\"bold\">III<\/text>\n      <rect x=\"74\" y=\"108\" width=\"180\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"164\" y=\"120\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Prepyloric<\/text>\n      <text x=\"164\" y=\"131\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">(&lt;3 cm from pylorus)<\/text>\n      <rect x=\"258\" y=\"108\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"323\" y=\"126\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">High<\/text>\n      <rect x=\"392\" y=\"108\" width=\"158\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"471\" y=\"120\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Behaves like DU;<\/text>\n      <text x=\"471\" y=\"131\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">good response to PPIs<\/text>\n      <!-- Type IV -->\n      <rect x=\"10\" y=\"138\" width=\"60\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"40\" y=\"156\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"9\" font-family=\"Georgia,serif\" font-weight=\"bold\">IV<\/text>\n      <rect x=\"74\" y=\"138\" width=\"180\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"164\" y=\"150\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">High lesser curvature<\/text>\n      <text x=\"164\" y=\"161\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">(near GEJ)<\/text>\n      <rect x=\"258\" y=\"138\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"323\" y=\"156\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Normal or low<\/text>\n      <rect x=\"392\" y=\"138\" width=\"158\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"471\" y=\"150\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Highest malignancy risk;<\/text>\n      <text x=\"471\" y=\"161\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">biopsy mandatory<\/text>\n      <!-- Type V -->\n      <rect x=\"10\" y=\"168\" width=\"60\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"40\" y=\"186\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"9\" font-family=\"Georgia,serif\" font-weight=\"bold\">V<\/text>\n      <rect x=\"74\" y=\"168\" width=\"180\" height=\"28\" rx=\"2\" fill=\"#f5f0fa\"\/>\n      <text x=\"164\" y=\"180\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Anywhere in stomach;<\/text>\n      <text x=\"164\" y=\"191\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">NSAID-induced<\/text>\n      <rect x=\"258\" y=\"168\" width=\"130\" height=\"28\" rx=\"2\" fill=\"#f5f0fa\"\/>\n      <text x=\"323\" y=\"186\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Normal or low<\/text>\n      <rect x=\"392\" y=\"168\" width=\"158\" height=\"28\" rx=\"2\" fill=\"#f5f0fa\"\/>\n      <text x=\"471\" y=\"180\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">No H. pylori association;<\/text>\n      <text x=\"471\" y=\"191\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">stop NSAID + PPI<\/text>\n    <\/svg>\n    <figcaption>\n      Modified Johnson's classification (5 types). <strong>NEET trap:<\/strong> Type I (incisura, normal\/low acid) is the MC gastric ulcer \u2014 do NOT confuse with duodenal ulcer (high acid). Type IV near GEJ = highest malignancy risk, technically most difficult surgery. Type V = NSAID-induced, unique in having no H. pylori link.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q4: Dumping Syndrome \u2014 Early vs Late -->\n<div id=\"surg01-img4\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 180\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"180\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Dumping Syndrome \u2014 Early vs Late<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"24\" width=\"130\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"145\" y=\"24\" width=\"195\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"345\" y=\"24\" width=\"205\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"75\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Feature<\/text>\n      <text x=\"242\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Early Dumping<\/text>\n      <text x=\"447\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Late Dumping<\/text>\n      <!-- Timing -->\n      <rect x=\"10\" y=\"48\" width=\"130\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"65\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Timing<\/text>\n      <rect x=\"145\" y=\"48\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"242\" y=\"65\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">15\u201330 min after eating<\/text>\n      <rect x=\"345\" y=\"48\" width=\"205\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"447\" y=\"65\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">1.5\u20133 hrs after eating<\/text>\n      <!-- Mechanism -->\n      <rect x=\"10\" y=\"76\" width=\"130\" height=\"36\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"94\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Mechanism<\/text>\n      <rect x=\"145\" y=\"76\" width=\"195\" height=\"36\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <text x=\"242\" y=\"88\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Hyperosmolar load in jejunum<\/text>\n      <text x=\"242\" y=\"100\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">\u2192 fluid shift \u2192 distension + VIP\/5-HT<\/text>\n      <rect x=\"345\" y=\"76\" width=\"205\" height=\"36\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"447\" y=\"88\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Rapid glucose absorption \u2192 insulin<\/text>\n      <text x=\"447\" y=\"100\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">overshoot \u2192 reactive hypoglycaemia<\/text>\n      <!-- Symptoms -->\n      <rect x=\"10\" y=\"114\" width=\"130\" height=\"36\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"132\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Symptoms<\/text>\n      <rect x=\"145\" y=\"114\" width=\"195\" height=\"36\" rx=\"2\" fill=\"#e8f3f9\"\/>\n      <text x=\"242\" y=\"126\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Flushing, palpitations, diarrhoea,<\/text>\n      <text x=\"242\" y=\"138\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">bloating, hypotension (vasomotor)<\/text>\n      <rect x=\"345\" y=\"114\" width=\"205\" height=\"36\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"447\" y=\"126\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Sweating, tremor, confusion,<\/text>\n      <text x=\"447\" y=\"138\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">palpitations (neuroglycopenic)<\/text>\n      <!-- Management -->\n      <rect x=\"10\" y=\"152\" width=\"540\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\" opacity=\"0.10\"\/>\n      <text x=\"280\" y=\"167\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Mx: small low-carb meals, no liquids with food, lie down post-meals \u00b7 Octreotide if refractory \u00b7 Roux-en-Y revision in severe cases<\/text>\n    <\/svg>\n    <figcaption>\n      Dumping syndrome occurs after any gastric surgery that disrupts pyloric function (gastrectomy, pyloroplasty, vagotomy). Early and late have completely different mechanisms \u2014 the exam frequently tests this distinction. <strong>Key identifier:<\/strong> early = vasomotor (flushing, diarrhoea immediately after eating); late = neuroglycopenic (sweating, confusion hours later).\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"surg01\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Surgery Series &middot; Round 01<\/div>\n    <div class=\"mr-title\">\n      Upper GI Surgery<br><em>Oesophagus, Stomach &amp; Duodenum<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Read carefully &middot; Trust your instinct<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"surg01-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"surg01-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"surg01-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"surg01-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"surg01-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"surg01-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"surg01-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"surg01-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"surg01-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"surg01-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"surg01-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"surg01-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"surg01-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"surg01-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #surg01 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'surg01';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'Upper GI &mdash; Achalasia',\n      stem:    'A <strong>38-year-old woman<\/strong> presents with a <strong>5-year history of progressive dysphagia<\/strong> \u2014 initially to solids, now equally to liquids. She reports regurgitation of undigested food, especially at night, with occasional episodes of coughing. She has lost 6 kg over 18 months. A barium swallow shows a dilated oesophageal body with a <strong>smooth, tapering narrowing at the gastro-oesophageal junction<\/strong>, described as a \"bird-beak\" appearance. High-resolution manometry confirms elevated LES resting pressure with <strong>absent LES relaxation<\/strong> and aperistalsis of the oesophageal body. What is the underlying pathophysiological defect and the <em>surgical<\/em> gold-standard treatment?',\n      correct: 'Loss of inhibitory (NO\/VIP) neurons in Auerbach\\'s plexus; Heller\\'s cardiomyotomy with partial fundoplication',\n      opts: [\n        'Loss of inhibitory (NO\/VIP) neurons in Auerbach\\'s plexus; Heller\\'s cardiomyotomy with partial fundoplication',\n        'Excess acetylcholine from Meissner\\'s plexus causing LES spasm; calcium channel blockers as definitive treatment',\n        'Extrinsic compression of the GEJ by mediastinal adenopathy (pseudoachalasia); pneumatic balloon dilation',\n        'Failure of LES inhibitory neurons due to autoimmune destruction; Nissen fundoplication'\n      ],\n      exp:     'Achalasia results from <strong>selective loss of inhibitory neurons<\/strong> (those secreting nitric oxide and VIP) in <strong>Auerbach\\'s (myenteric) plexus<\/strong> at the GEJ. The result is a tonically contracted LES that fails to relax on swallowing, and loss of normal progressive peristalsis in the oesophageal body. The classic barium finding is the <strong>bird-beak or rat-tail sign<\/strong> \u2014 dilated oesophagus narrowing smoothly to the non-relaxing LES. <br><br>Gold-standard <strong>diagnosis<\/strong>: high-resolution manometry (HRM). Gold-standard <strong>surgical treatment<\/strong>: <strong>Heller\\'s cardiomyotomy<\/strong> (laparoscopic division of circular muscle fibres at the GEJ) combined with a <strong>partial (Dor or Toupet) fundoplication<\/strong> to prevent postoperative GORD. POEM (per-oral endoscopic myotomy) is an emerging endoscopic equivalent. <br><br><strong>Critical trap \u2014 pseudoachalasia:<\/strong> carcinoma of the GEJ (or extrinsic compression) can mimic achalasia on manometry. Suspect it when age &gt;55, symptom duration &lt;1 year, or rapid weight loss. Endoscopy with biopsy is mandatory before any intervention.',\n      imgId:   'surg01-img1'\n    },\n\n    {\n      id:      2,\n      tag:     'Upper GI &mdash; Corrosive Oesophagitis',\n      stem:    'A <strong>4-year-old child<\/strong> is brought to casualty 2 hours after accidentally ingesting household bleach (a strong alkaline agent). He is drooling, refuses to swallow, and has oropharyngeal burns. Vitals are stable; chest X-ray is normal. The parents are asking about the next step in management. Which statement about the management of corrosive oesophageal injury is <em>most accurate<\/em>?',\n      correct: 'Upper GI endoscopy should be performed within 12&ndash;24 hours to grade the injury and guide management',\n      opts: [\n        'Upper GI endoscopy should be performed within 12&ndash;24 hours to grade the injury and guide management',\n        'Induced vomiting should be performed immediately to clear the ingested alkali from the oesophagus',\n        'Barium swallow is the first investigation of choice to assess the extent of injury',\n        'Neutralisation with a weak acid (vinegar) should be given orally to counteract the alkali'\n      ],\n      exp:     'In corrosive ingestion, the <strong>priority<\/strong> after stabilisation is <strong>upper GI endoscopy within 12&ndash;24 hours<\/strong> (some guidelines say 6\u201324 hrs) to grade the burn (Zargar classification: Grade 0 = normal \u2192 Grade 3b = extensive necrosis). This guides management \u2014 Grades 0\u20132a can be managed conservatively; Grade 2b\u20133 may need ICU, parenteral nutrition, or emergency surgery. <br><br><strong>Never induce vomiting<\/strong> \u2014 re-exposure of the oesophagus to the caustic agent causes further injury and increases aspiration risk. <strong>Never neutralise<\/strong> \u2014 the exothermic reaction of acid + alkali causes a thermal burn superimposed on the chemical burn. <strong>Barium swallow<\/strong> is not the first investigation \u2014 it can miss mucosal injury and is not used acutely. <br><br><strong>Alkali vs acid:<\/strong> alkalis (lye, bleach) cause <strong>liquefactive necrosis<\/strong> \u2014 penetrate deep and cause more oesophageal injury. Acids cause <strong>coagulative necrosis<\/strong> with eschar formation, which is somewhat self-limiting, and tend to injure the stomach more. <strong>Late complication:<\/strong> oesophageal stricture (weeks to months later) \u2014 managed with serial dilatations; surgical oesophageal replacement (gastric pull-up or colonic interposition) in refractory stricture.',\n      imgId:   null\n    },\n\n    {\n      id:      3,\n      tag:     'Upper GI &mdash; Peptic Ulcer Disease',\n      stem:    'A <strong>52-year-old man<\/strong> with a 6-month history of epigastric pain relieved by food presents for upper GI endoscopy. Endoscopy reveals a <strong>solitary ulcer at the incisura angularis<\/strong> on the lesser curvature of the stomach. Biopsies show chronic inflammation with <em>H. pylori<\/em> positivity; no dysplasia. Serum gastrin is normal. Which statement most accurately describes this ulcer according to the Modified Johnson\\'s Classification and its management principle?',\n      correct: 'Type I gastric ulcer; normal or low acid secretion; treat with H. pylori eradication + PPI, and re-scope at 8 weeks to confirm healing',\n      opts: [\n        'Type I gastric ulcer; normal or low acid secretion; treat with H. pylori eradication + PPI, and re-scope at 8 weeks to confirm healing',\n        'Type II gastric ulcer; high acid secretion; management mirrors that of duodenal ulcer with vagotomy if surgery needed',\n        'Type III gastric ulcer; prepyloric location; associated with normal acid and high malignancy risk',\n        'Type IV gastric ulcer; near GEJ; highest malignancy risk; requires total gastrectomy as first-line'\n      ],\n      exp:     'An ulcer at the <strong>incisura angularis on the lesser curvature<\/strong> is a <strong>Type I gastric ulcer<\/strong> in the Modified Johnson\\'s Classification \u2014 the most common type (~60%). Key features of Type I: <strong>normal or low acid<\/strong> secretion (unlike duodenal ulcers), strong <em>H. pylori<\/em> association, and it does <em>not<\/em> behave like a duodenal ulcer. <br><br><strong>Management:<\/strong> H. pylori eradication (triple or quadruple therapy) + PPI for 8 weeks, followed by <strong>mandatory repeat endoscopy<\/strong> to confirm healing and exclude malignancy. All gastric ulcers must be biopsied \u2014 multiple biopsies from the ulcer edge (at least 6\u20138). <br><br><strong>Modified Johnson\\'s \u2014 rapid recap:<\/strong> Type I = incisura, low acid (MC); Type II = body + duodenal ulcer, high acid; Type III = prepyloric, high acid (behaves like DU); Type IV = near GEJ, low acid, highest malignancy risk; Type V = anywhere, NSAID-induced, no H. pylori. <br><br><strong>Surgical indication:<\/strong> failure of medical therapy, perforation, bleeding, obstruction, or suspicion of malignancy. Procedure for Type I: distal gastrectomy (Billroth I preferred \u2014 end-to-end gastroduodenostomy; avoids bile reflux better than Billroth II).',\n      imgId:   'surg01-img3'\n    },\n\n    {\n      id:      4,\n      tag:     'Upper GI &mdash; Post-Gastrectomy Dumping',\n      stem:    'A <strong>48-year-old man<\/strong> underwent <strong>Billroth II gastrectomy<\/strong> 6 weeks ago for a perforated gastric ulcer. He now complains that <strong>15\u201320 minutes after every meal<\/strong> he develops sweating, palpitations, facial flushing, and loose stools. He feels lightheaded but his blood glucose checked during an episode was <strong>normal (5.2 mmol\/L)<\/strong>. He has lost a further 3 kg since surgery. Which is the most likely diagnosis and the single most important dietary modification?',\n      correct: 'Early dumping syndrome; eat small, frequent, low-carbohydrate meals and avoid fluids with food',\n      opts: [\n        'Early dumping syndrome; eat small, frequent, low-carbohydrate meals and avoid fluids with food',\n        'Late dumping syndrome; eat high-carbohydrate snacks 2 hours after main meals to prevent hypoglycaemia',\n        'Afferent loop syndrome; lie in the left lateral position after meals to promote bile drainage',\n        'Roux-en-Y stasis syndrome; prokinetic agents (metoclopramide) are the first-line treatment'\n      ],\n      exp:     'The timing \u2014 <strong>15\u201320 minutes after eating<\/strong> \u2014 and the vasomotor symptoms (flushing, palpitations, diarrhoea) with a <strong>normal blood glucose<\/strong> during the episode point firmly to <strong>early dumping syndrome<\/strong>. <br><br><strong>Mechanism:<\/strong> without a pylorus, hyperosmolar food boluses enter the jejunum rapidly \u2192 osmotic fluid shift from intravascular to gut lumen \u2192 bowel distension \u2192 release of vasoactive peptides (VIP, serotonin, bradykinin) \u2192 vasomotor symptoms. Blood glucose is normal or slightly elevated (not low) during early dumping. <br><br><strong>Late dumping<\/strong> occurs 1.5\u20133 hours after eating: rapid glucose absorption \u2192 exaggerated insulin release \u2192 reactive hypoglycaemia \u2192 neuroglycopenic symptoms (sweating, tremor, confusion). Blood glucose is low (&lt;3.5 mmol\/L) during the episode. <br><br><strong>Dietary management (first-line for early dumping):<\/strong> small, frequent meals; low simple carbohydrates; <strong>no fluids with meals<\/strong> (fluids accelerate gastric emptying); lie down after eating. Octreotide is reserved for refractory cases. Surgical revision (Roux-en-Y) for severe medically refractory dumping. <br><br><strong>Afferent loop syndrome<\/strong> presents with bilious vomiting relieved by a large vomit 20\u201330 min after eating \u2014 different picture entirely.',\n      imgId:   'surg01-img4'\n    },\n\n    {\n      id:      5,\n      tag:     'Upper GI &mdash; Upper GI Bleed',\n      stem:    'A <strong>45-year-old man<\/strong> with no alcohol history presents with <strong>two episodes of haematemesis<\/strong>. On examination: BP 94\/60 mmHg, PR 118\/min, splenomegaly, mild ascites, and dilated abdominal veins. Haemoglobin is 7.2 g\/dL, platelet count 62,000\/&mu;L, PT-INR 1.8. Upper GI endoscopy reveals <strong>bleeding oesophageal varices<\/strong> (Gr III). He is resuscitated with IV fluids and blood. What is the most appropriate <em>immediate pharmacological<\/em> intervention alongside endoscopic band ligation?',\n      correct: 'IV terlipressin (or octreotide \/ somatostatin); to reduce portal pressure and control variceal bleeding',\n      opts: [\n        'IV terlipressin (or octreotide \/ somatostatin); to reduce portal pressure and control variceal bleeding',\n        'IV pantoprazole infusion; to reduce acid-peptic injury to the varix and promote clot stability',\n        'IV vasopressin alone at maximum dose; superior to terlipressin and has fewer cardiac side effects',\n        'Immediate Sengstaken-Blakemore tube insertion as the first-line manoeuvre before endoscopy'\n      ],\n      exp:     'In acute variceal bleeding, endoscopic band ligation (EBL) is the <strong>endoscopic treatment of choice<\/strong>. The pharmacological agent started as soon as variceal bleed is suspected (even before endoscopy) is a <strong>vasoactive drug<\/strong>: <br><br>&bull; <strong>Terlipressin<\/strong> (V1 agonist) \u2014 preferred in most guidelines; reduces portal pressure by splanchnic vasoconstriction; shown to reduce mortality; 2 mg IV every 4 hrs, then 1 mg after bleeding controlled. <br>&bull; <strong>Octreotide \/ somatostatin<\/strong> \u2014 equally effective; inhibit glucagon and splanchnic vasodilatation; used where terlipressin unavailable (e.g. USA). <br><br><strong>PPI infusion<\/strong> is appropriate for peptic ulcer bleeding (Rockall score-based), not variceal bleeding \u2014 PPIs do not reduce portal hypertension. <br><br><strong>Vasopressin<\/strong> (pure V1\/V2 agonist) causes significant systemic and coronary vasoconstriction (MI, arrhythmia) \u2014 always given with nitroglycerine to offset these effects; terlipressin is preferred as it is V1-selective and has a better safety profile. <br><br><strong>Sengstaken-Blakemore tube<\/strong> is a <em>bridge<\/em> when endoscopy fails or is unavailable \u2014 not a first-line move. <strong>Prophylactic antibiotics<\/strong> (ceftriaxone) are also mandatory in all cirrhotics with variceal bleed \u2014 reduces bacterial translocation, SBP, and rebleeding risk.',\n      imgId:   null\n    }\n\n  ];\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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